UMMC COVID-19 Vaccine Appointment Confirmation or Change Request Form

The purpose of this form is to submit a request related to one of the following... 1) Cancel FIRST dose appointment without rescheduling 2) Cancel FIRST dose appointment and reschedule 3) Reschedule Pfizer booster appointment 4) Reschedule Moderna booster appointment 5) Schedule Pfizer booster appointment 6) Schedule Moderna booster appointment 7) Confirm scheduled appointment Please note this form should ONLY be used for one of the reasons above at the Downtown Campus clinic, which is located in T1R15 across from the UMMC Auditorium. If you need to cancel, reschedule, or confirm an appointment at the Baltimore Convention Center Field Hospital (BCCFH), please do not submit this form and instead call (410)649-6200. If this request is for Six Flags or M&T Stadium, please call 1-855-MDGOVAX. If this request is for the Midtown Campus, email SpecialVaccineRequest@umm.edu. If this request is for the Southern Management Corporation (SMC) Campus Center, email vaccinescheduling@umaryland.edu or call (410)706-3000. If you have questions related to vaccine distribution, employee vaccinations, or safety and effectiveness, please review the FAQs on the *UMMC Insider (http://intra.umms.org/umms/coronavirus/vaccine-guidance/faqs) *UMMC virtual private network (VPN) access is required to view this page.

This form is NOT for requests related to the Baltimore Convention Center Field Hospital (BCCFH), Six Flags, M&T Stadium, Midtown Campus, or SMC as this team does not manage these vaccination locations. Please see above for the phone numbers for these locations.

Location of Vaccination*

If this request is for the Midtown Campus, email SpecialVaccineRequest@umm.edu. If this request is for the Southern Management Corporation (SMC) Campus Center, email vaccinescheduling@umaryland.edu or call (410)706-3000.

Downtown Campus Hospital Clinic (T1R15)

FIRST Name*

LAST Name*

Preferred Email Address*

You will receive follow-up communication related to your request to this email address.

Preferred Email Verification*

Please retype your preferred email address again to ensure it is valid. If your email address is invalid, you will NOT be able to receive follow-up communications.

Preferred Telephone Number*

Date of Birth*

Example: 01/01/1994

Home Address*

Employer or Affiliation*

Select

Reason for Request*

Cancel FIRST dose appointment without rescheduling

Cancel FIRST dose appointment and reschedule

Reschedule Pfizer booster appointment

Reschedule Moderna booster appointment

Schedule Pfizer booster appointment

Schedule Moderna booster appointment

Confirm scheduled appointment

Appointment Confirmation Number

If available, please type the 10 digit confirmation number that appears on your appointment confirmation.

Date of EXISTING Scheduled Appointment to Confirm*

Time of EXISTING Scheduled Appointment to Confirm*

Example: 1:00PM

Date of EXISTING Appointment for First Dose*

Please note that after your first dose appointment is canceled, and if you wish to reschedule, you may be directed to reschedule using the scheduling link you used for your prior appointment.

Time of EXISTING Appointment for First Dose*

Example: 1:00PM

Date of EXISTING Booster Appointment to Reschedule*

Time of EXISTING Booster Appointment to Reschedule*

Example: 1:00PM

Date of First Dose*

As you already received your first dose, list the date in which it was administered.

Comments for Scheduling Booster*

List the reason for which you are requesting to schedule your booster (e.g., I received my first dose at another facility outside of Maryland, I experienced an illness or symptoms after my first dose). Please also include three (3) preferred dates for the scheduling of your booster.

Dates for Rescheduling*

Please include three (3) preferred dates for the rescheduling of your booster. T1R15 is open Tuesdays - Thursdays from 7:00AM - 3:30PM. Note: The recommendation from Infection Prevention is for the booster for Pfizer to occur around but not before 21 days after the first dose. The booster for Moderna is to occur around but not before 28 days after the first dose.

Preferred Time Range(s)*

Select as many ranges in which you are available.

Select

File Upload for CDC Vaccination Card (Recommended)

If possible, upload a copy of your CDC vaccination card with your first dose information for the team's review.

Drag and drop files here or

I understand that I am CANCELLING my COVID-19 vaccine appointment.*

Please check this box to verify the statement above is true.

After the Patient Access Services (PAS) team has the opportunity to review your request, you will be contacted through the preferred email address listed above. Responses typically occur within one business day. Please do NOT resubmit this form with a duplicate request as this will cause confusion for the PAS team and will result in further delays.

Privacy Notice|Report Abuse